Fluoroquinolones-induced tendinitis and tendon rupture in kidney transplant recipients: 2 cases and a review of the literature.

Fluoroquinolones are an important class of synthetic antibiotics and their use recently expanded with a new activity against Gram positive and anaerobics. In the literature many side effects were documented and, among them, tendinitis and subsequent tendon rupture are important causes of morbidity. The incidence is 0.14% to 0.4% but, in the kidney recipient population, the phenomenon is even more common (incidence, 12.2%-15.6%). Advanced age seems to be the most significant risk factor. Long period of hemodialysis, diabetes mellitus, hyperparathyroidism, rheumatic diseases, gout, and corticosteroids are the other predisposing factors in kidney recipients, even if they are still under discussion. All of these risk factors can create a synergistic toxicity or at least an additive effect. A case of tendinitis and a case of bilateral Achilles tendon ruptures in 2 kidney recipients are described and a brief discussion of the literature is presented.

Graft failure due to hemolytic uremic syndrome recurrence.

The hemolytic uremic syndrome (HUS) is a severe disease characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure. We herein report our experience with a 43-year-old female patient who underwent a second cadaveric kidney transplantation in February 2005, for adult-onset HUS. The first renal transplantation, which was performed in 1996, required removal after 3 weeks for probable recurrence of HUS. The immunosuppressive regimen for the second transplant included basiliximab, tacrolimus, mycophenolate mofetil, and steroids. On postoperative day (POD) 7, she received steroid treatment for an acute rejection episode with improved renal function. On POD 19 due to worsening renal function, a graft biopsy showed HUS recurrence, thus we instituted hemodialysis and then plasmapheresis treatments. At two months after transplantation, the patient continued under plasmapheresis treatment due to clinical evidence of HUS. On POD 80, cytomegalovirus infection was diagnosed and intravenous gancyclovir treatment started for 3 weeks. After 110 days from transplant, a deterioration in renal function was evident: the graft was swollen and painful with Doppler ultrasound showing patency of both the renal artery and vein but, low blood flow. After 2 weeks of hemodialysis, the patient underwent transplantectomy. In adult-onset HUS the recurrence rate reduces graft survival, particularly among patients undergoing second transplantation.

Interposition of the right colic angle between the liver and thoracic wall: an unusual cause of massive rectal bleeding following percutaneous biopsy in a liver transplant recipient.

A 37-year-old male liver transplant recipient developed hemorrhagic shock from massive rectal bleeding a few hours after a protocol liver biopsy. Conservative treatment was not possible and the patient underwent a radiological investigation of the celiac and mesenteric arterial trunks, which showed active bleeding from a branch of the middle colic artery. Embolization with Tabotamp (Ethicon, Neuchatel, CH Switzerland) particles led to successful hemostasis. We thus discuss the possible mechanisms of injury. To our knowledge, no other cases of major rectal bleeding following percutaneous liver biopsy have been reported in the literature. We emphasize the need for Doppler ultrasound assistance, in terms of either preoperative examination with or without marking or guidance. The latter is the safest and most reliable technique, given the low risk of puncture of other organs and the low probability of obtaining an inadequate sample.

Amantadine monotherapy is ineffective in the treatment of hepatitis C virus recurrence in the post-liver transplantation setting.

BACKGROUND: Recurrent hepatitis C virus (HCV) infection is universal after liver transplantation (LT), yet no effective therapy is available. Amantadine (Am) is currently under evaluation. The aim of this study was to assess the safety and the effectiveness of Am monotherapy in LT patients with HCV recurrence. METHODS: Twelve patients who underwent transplantation 1-4 years earlier were included when there was detectable serum HCV-RNA and histological signs of liver damage with evidence of progressive hepatic fibrosis. Basal Ishak's scores were 2.1 +/- 1.3 and 5.1 +/- 2.7, respectively. Exclusion criteria were histological cirrhosis and comorbidities. All patients were receiving cyclosporine, with or without azathioprine. Amantadine was given orally (200 mg/d) for 3 months. RESULTS: Eight (67%) patients completed a 3-month treatment course without dose adjustments. Am was reduced to 100 mg/d in 3 cases and withdrawn in 1 due to side effects, namely, insomnia (n = 7; 58%), tremor (n = 4; 33%), headache (n = 2; 17%), asthenia (n = 2; 17%), and dermatitis, diarrhea, and increased creatinine (each n = 1; 8%). Serum HCV-RNA levels decreased in 3 patients, increased in 3, and remained unchanged in the others. Alanine aminotransferase (ALT) remained abnormal in all cases. Liver function test results did not improve. CONCLUSIONS: Short-term Am monotherapy was ineffective to treat post-LT HCV relapse and was associated with significant side effects.

[Intraoperative radiolocalization of intraductal breast carcinoma: sentinel lymph node evaluation]. / La radiolocalizzazione intraoperatoria nel carcinoma intraduttale della mammella: valutazione del linfonodo sentinella.

Sentinel lymph node biopsy and intraoperatory radiolocalization (RLI) are fast becoming the standard surgical treatment for invasive breast cancer. Actually, it seems, they have the same rule in "high risk" DCIS of the breast.

[Video laparoscopic cholecystectomy in acute cholecystitis: when,how and why?]. / La videolaparocolecistectomia nella colecistite acuta. Quando, come e perché?

Acute cholecystitis has been previously considered as contraindication for laparoscopic cholecystectomy (LC), but recently, several studies have demonstrated that the laparoscopic approach can also be effective in such cases, although iatrogenic lesions of the biliary tree have been increasingly reported. Aim of this study was to verify the effectiveness of LC in patients presenting with acute cholecystitis on the basis of preoperative and intraoperative findings, postoperative mortality and morbidity, in order to assess those conditions which still can be considered as contraindications for LC. From September 1992 to January 1995, 133 patients have been consecutively admitted and operated for LC. 46 cases (36.5%) had histologically proven acute cholecystitis. Moreover we have compared preoperative date (clinical history, laboratory findings, Rx and ultrasound evaluation) with intraoperative findings to assess a correlation with intraoperative difficult conditions evaluated according to De Manzini score. Our results demonstrate that clinical data significantly correlate with intraoperative difficult situations. Hepatobiliary ultrasound also has shown good correlation between the thickness of gallbladder wall and difficult operations (73.9 sensibility-70.1 specificity). Therefore, in patients with clinically severe acute cholecystitis, and thickened gallbladder demonstrated by ultrasound it is very likely that the surgeon will experience difficult in intraoperative situations. In these conditions laparoscopy may be considered mainly as a diagnostic procedure in order to evaluate the entity of inflammatory changes considering the possibility of an open conversion that must be done before any iatrogenic lesion occur. This policy has allowed us to avoid in our series postoperative complications such as lesions of the biliary tree. In conclusion we believe that LC for acute cholecystitis should be considered as a therapeutical option only for selected cases.

[Digestive endometriosis: an isolated case localized in the ileum and occlusive course]. / L'endometriosi digestiva: su un caso a localizzazione ileale, isolata, ad evoluzione occlusiva.

The authors starting from the description of a clinical case of intestinal endometriosis, who underwent emergency surgery for acute intestinal obstruction, take into consideration the incidence, the pathogenesis and the pathological characteristics of intestinal endometriosis. They attempt to define it while accepting that the indications for resection should be extremely limited from both gynecological and intestinal points view.

[THe video laparoscopic experience of the general surgeon in cholecystectomy in childhood]. / L'esperienza videolaparoscopica del chirurgo generale nella colecistectomia in età pediatrica.

Despite the exponentially increasing number of laparoscopic cholecystectomies on adults to date, there is a paucity of reports in the literature about this new technique in pediatric patients. From September 1992 to February 1995, 140 patients underwent laparoscopic cholecystectomy. Since July 1993, in our institution, five pediatric patients (three females and two males) with a diagnosis of cholelithiasis underwent laparoscopic cholecystectomy. The age of the patients ranged from 6 to 15 years (mean 8.8 years) and they weighed 18-58 kg (mean 28.4 kg). All five patients had biliary cholic and ultrasound evidence of cholelithiasis. One patient had associated hematological disease (sickle cell disease). All 5 children were operated using the laparoscopic approach technique. Operative cholangiography was performed in cases with ductal and vascular intraoperative anatomy unclear. No operation was converted to open cholecystectomy. Intraoperative cholangiography was performed successfully (100%). The mean time of surgery was 50.2 minutes (range from 38 to 68). There were no operative complications. The mean hospital stay was 2.2 days (range 2 to 3 days). All five returned to their activity within a week. No long-term complications were seen in all patients throughout an average follow-up period of 10.6 months (range 8-14). The benefits of laparoscopic cholecystectomy in children are clear and obvious. It is safe and effective and should now be the treatment of choice for cholelithiasis in pediatric patients.

[Chronic abdominal pain: role of video-laparoscopic adhesiolysis]. / Il dolore addominale cronico: ruolo della adesiolisi videolaparoscopica.

Adhesions have been suggested as a possible cause of chronic abdominal pain, but the reports of their etiological role conflict. Lysis of adhesions has been proposed as the therapeutic modality of choice, although the reports of success are controversial. The aim our prospective study was to determine whether laparoscopic adhesiolysis ameliorates chronic abdominal pain in patients with abdominal adhesions. Forty-one patients with chronic abdominal pain lasting for more than 6 months, but with no abnormal findings other than adhesions found at laparoscopy, underwent laparoscopic adhesiolysis. 37 patients (90.2%) were available for follow-up after a median time interval of 18 months (range: 12-41 months). Twenty-two patients (59.4%) were free from abdominal pain and 9 (24.3%) patients reported significant amelioration of their pain. Six (16.2%) patients had no amelioration. In conclusion the laparoscopy is an effective tool for the evaluation of patients with chronic abdominal pain, and laparoscopic adhesiolysis cures of ameliorates chronic abdominal pain in more than 80% of patients.

[Head trauma in a general surgery department: observations, diagnostic and therapeutic indications]. / Il trauma cranico in una divisione di chirurgia generale: osservazioni, indicazioni diagnostiche e terapeutiche.

UNLABELLED: The authors reviewed the records of 927 patients admitted to Surgical Clinic University of L'Aquila from November 1986 to July 1990 with head trauma. The 5.6% (52 patients) had skull fractures. 23 (2.4%) patients sustained significant intracranial sequelae from their injuries, but only 4 (17.3%) of these also sustained fractures, 17 did not. Of the four fractures 1 were simple, 2 was depressed and 1 was basilar. The patients (17) without a skull fracture and positive CT were transferred to a neurosurgical department, where 12 underwent operation. The patients (4) with a skull fracture and positive CT and 2 patients with a depressed skull fracture and negative CT were transferred to a neurosurgical department where 5 (except 1 patient with simple fracture) underwent operation. The severity of coma was evaluated according to Glasgow Coma Scale (G.C.S.). The 2.4% of patients had the Glasgow Coma Scale = or less than 7. The CT or MNR are indicate in the presence of neurologic abnormalities. Overall mortality rate was about 0.53%. In the severe head trauma (G.C.S. = or less than 7) was of 17,3. IN CONCLUSION: the skull radiography is not indicated of routine and are performed for the evaluation of depressed fractures, of fracture of the cranial base and of cervical vertebrae: the MNR was found to be superior to CT and to be very effective in the detection of traumatic head lesions: the Glasgow Coma Scale is important for monitoring, stratification and prognostic evaluation of patients.

[Postoperative esophageal-visceral fistulae: their prevention and treatment]. / Fistole esofago-viscerali postoperatorie: prevenzione e trattamento.

A series of 12 cases of esophageal anastomotic leakage following esophageal surgery observed from 1969 to 1989 is retrospectively analyzed. In the period 1969-1975 6 patients were treated in emergency and the mortality rate was 66.6%, while the remaining 6 patients observed from 1975 to 1989 were treated conservatively with total parenteral nutrition (sometimes associating adequate surgical drainage): the mortality rate was 16.6%. In conclusion, not only in the treatment of anastomotic leakage, but also in its prevention, artificial nutrition has a crucial role. The outcome of thoracic and abdominal fistulas depends mainly on adequate drainage, not necessarily surgical. Cervical fistulas heal in 2-4 weeks, but strictures arise frequently and respond to endoscopic dilatation.